quick reference: guideline for primary care …€¦ · behavioural management • headache diary:...

No Yes Yes Quick Reference: GUIDELINE FOR PRIMARY CARE MANAGEMENT OF HEADACHE IN ADULTS Red flags: Emergent (address immediately) • Thunderclap onset • Fever and meningismus • Papilloedema (+focal signs or reduced LOC) • Acute glaucoma Yes Refer and/or investigate Headache with 2 or more of: • Nausea • Light sensitivity • Interference with activities Practice points: • Migraine historically under diagnosed • Consider migraine diagnosis for recurring “sinus” headache Headache w/o nausea and 2 or more of: • Bilateral headache • Non‐pulsating pain • Mild to moderate pain • Not worsened by activity All of: • Frequent headache • Severe • Brief < 3 hours per attack • Unilateral (always same side) • Ipsilateral eye redness, tearing and/or restlessness during attacks All of: • Unilateral headache (always same side) • Continuous • Dramatically responsive to indomethacin Headache continuous since onset Medication overuse: Assess • Ergots, triptans, combination analgesics or codeine/other opioids ≥ 10 days a month OR • Acetaminophen or NSAIDs ≥ 15 days a month Manage • Educate patient • Consider prophylactic medication • Provide an effective acute med for severe attacks with limitations on frequency of use • Gradual withdrawal if opioid, or combination analgesic with opioid or barbituate • Abrupt (or gradual) withdrawal if acetaminophen, NSAIDs or triptan Tension‐type headache • Acute medication (Table 2) • Monitor for medication overuse • Prophylactic medication if disability despite acute meds (Table 2) Cluster headache or another trigeminal autonomic cephalalgia • Management primarily pharmacological • Acute medication (Table 3) • Prophylactic medication (Table 3) • Early specialist referral recommended Migraine • Acute medication (Table 1) • Monitor for medication overuse • Prophylactic medication (Table 1), if headache: > 3 days/month and acute meds not effective OR > 8 days/month (risk of overuse) OR Disability despite acute meds Yes Migraine Yes Tension-type Headache Hemicrania continua • specialist referral New daily persistent headache • specialist referral Yes No The above recommendations are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. They should be used as an adjunct to sound clinical decision making. Behavioural management • Headache diary: record frequency, intensity, triggers and medication • Adjust lifestyle factors: reduce caffeine, ensure regular exercise, avoid irregular and/or inadequate sleep or meals • Stress management: relaxation training, CBT, pacing activity, biofeedback Uncommon headache syndromes No Urgent (address hours to days) • Temporal arteritis • Papilloedema (NO focal signs or reduced LOC) • Relevant systemic illness • Elderly: new headache with cognitive change Possible indicators of secondary headache: • Unexplained focal signs • Atypical headaches • Unusual headache precipitants • Onset after age 50 • Aggravation by neck movement; abnormal neck exam. Consider cervicogenic headache. • Jaw symptoms; abnormal jaw exam. Consider temporomandibular disorder. July 2012

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Page 1: Quick Reference: GUIDELINE FOR PRIMARY CARE …€¦ · Behavioural management • Headache diary: record frequency, intensity, triggers and medication • Adjust lifestyle factors:

Yes

Quick Reference: GUIDELINE FOR PRIMARY CARE MANAGEMENT OF HEADACHE IN ADULTS

Red �ags:Emergent (address immediately)• Thunderclap onset• Fever and meningismus• Papilloedema (+focal signs or reduced LOC)• Acute glaucoma

Yes Refer and/or investigate

Headache with 2 or more of:• Nausea• Light sensitivity• Interference with activities

Practice points:• Migraine historically under diagnosed• Consider migraine diagnosis for recurring “sinus” headache

Headache w/o nausea and 2 or more of:• Bilateral headache• Non‐pulsating pain• Mild to moderate pain• Not worsened by activity

All of:• Frequent headache• Severe• Brief < 3 hours per attack• Unilateral (always same side)• Ipsilateral eye redness, tearing and/or restlessness during attacks

All of:• Unilateral headache (always same side)• Continuous• Dramatically responsive to indomethacin

Headache continuous since onset

Medication overuse:Assess• Ergots, triptans, combination analgesics or codeine/other opioids ≥ 10 days a month OR• Acetaminophen or NSAIDs ≥ 15 days a monthManage• Educate patient• Consider prophylactic medication• Provide an effective acute med for severe attacks with limitations on frequency of use• Gradual withdrawal if opioid, or combination analgesic with opioid or barbituate• Abrupt (or gradual) withdrawal if acetaminophen, NSAIDs or triptan Tension‐type headache

• Acute medication (Table 2)• Monitor for medication overuse• Prophylactic medication if disability despite acute meds (Table 2)

Cluster headache or another trigeminal autonomic cephalalgia• Management primarily pharmacological• Acute medication (Table 3)• Prophylactic medication (Table 3)• Early specialist referral recommended

Migraine• Acute medication (Table 1)• Monitor for medication overuse• Prophylactic medication (Table 1), if headache: > 3 days/month and acute meds not effective OR > 8 days/month (risk of overuse) OR Disability despite acute meds

Yes

Migraine

Yes

Tension-typeHeadache

Hemicrania continua • specialist referral

New daily persistent headache • specialist referral

Yes

The above recommendations are systematically developed statements to assist practitioner and patient decisions about appropriate health carefor specific clinical circumstances. They should be used as an adjunct to sound clinical decision making.

Behavioural management• Headache diary: record frequency, intensity, triggers and medication• Adjust lifestyle factors: reduce caffeine, ensure regular exercise, avoid irregular and/or inadequate sleep or meals• Stress management: relaxation training, CBT, pacing activity, biofeedback

Uncommon headache syndromes

Urgent (address hours to days)• Temporal arteritis• Papilloedema (NO focal signs or reduced LOC)• Relevant systemic illness• Elderly: new headache with cognitive change

Possible indicators of secondary headache:• Unexplained focal signs• Atypical headaches• Unusual headache precipitants• Onset after age 50

• Aggravation by neck movement; abnormal neck exam. Consider cervicogenic headache.• Jaw symptoms; abnormal jaw exam. Consider temporomandibular disorder.

July 2012